PROJECT SUMMARY/ABSTRACT Yup?ik children in Alaska?s YK Delta consume 50 teaspoons of added sugar each day, 16 times the American Heart Association?s recommended maximum. Most of this added sugar is from sugared fruit drinks (mostly Tang and Kool-Aid) consumed at home. Consequently, Yup?ik children experience tooth decay rates that are 16 times the U.S. average and suffer from oral health inequalities compared to children from better off communities. We propose a 2-arm quasi-experimental behavioral trial in 3 rural Alaska Native communities to test the hypothesis that Community Health Worker-led health education and self-efficacy training for caregivers will decrease child added sugar intake. The Specific Aims are to: (1) Refine and finalize the health promotion intervention; (2) Implement the intervention and determine outcomes; and (3) Identify intervention improvement strategies and disseminate findings. Beverage substitution interventions involving health education and access to alternatives are effective, but improvements are not typically sustained long-term. The reason for this drop off is that the interventions lack specific efforts to boost self-efficacy, a critical omission according to Bandura?s Social Cognitive Theory. This application builds on previous research and will test these concepts in Alaska Native communities. In the proposed study, 3 communities will be assigned to 1 of 2 arms based on the order in which the community is ready. 101 families with children ages 0-10 years in 2 Yup?ik communities will be recruited to test the 6-month culturally-adapted, 5-session intervention consisting of interactive health education and self-efficacy training delivered in-person by an indigenous Community Health Worker. 41 families in a third Yup?ik community will be recruited to a comparison condition in which health education with the same culturally-adapted content will be delivered by mail. Health education will address tooth decay etiology and misinformation about sugared fruit drinks, and promote sugar-free water enhancers. Self-efficacy training will empower caregivers to initiate and sustain behavior change over time. Local stores in all 3 communities will stock sugar-free fruit drinks (Tang and Kool-Aid drops, also called water enhancers by industry) as a tool to help shift children from sugared fruit drinks. The primary outcomes at the child level are sugared fruit drink intake (caregiver-reported 24-hour recalls) and added sugar intake (through a validated, non-invasive biomarker) measured at baseline and at 1, 3, 6, and 12 months. Secondary outcomes include % total energy intake from added sugar and caregiver self-efficacy to provide alternatives. This work has the support of the Yukon Kuskokwim Health Corporation which will maintain and disseminate the program if it works and can address a critical problem facing over 15,000 Alaska Native children in the YK Delta and millions more if adopted throughout Alaska and American Indian country in the Lower 48. Moreover, it can be adapted to meet the needs of other populations with similar problems.